Bilateral primary adrenal non-Hodgkin′s lymphoma without adrenal insufficiency

Abstract

We are presenting a rare case of bilateral adrenal non-Hodgkin's lymphoma (NHL) that presented as a primary malignancy. An 83-year-old man presented with newly discovered bilateral adrenal incidentalomas, fatigue, and 30 pound weight loss. Of the 116 cases of primary adrenal NHL reported, over half have presented bilaterally and occur with adrenal insufficiency. Therefore, the finding of bilateral adrenal masses requires an urgent work-up of the functional status of the adrenal gland as well as a thorough analysis of the imaging characteristics seen on noncontrast computed tomography (CT) in order to maximize patient survival. Adrenal function testing was normal. Repeat CT imaging revealed rapidly growing lesions with high attenuations; both masses >10 HU. Histological examination of core biopsies discovered malignant lymphoma with no known past history of lymphoma. Our case coincides with the literature, which states that a mass with attenuation >10 HU in the adrenal glands has a high risk of malignancy.

Bilateral adrenal lymphoma with adrenal insufficiency: a case report with litretures review

“…19 Background of preceding autoimmune adrenalitis and direct infiltration by neoplasm are mechanisms which could explain the adrenal insufficiency that is regularly observed in patients with PAL, The non-particular symptoms and signs of adrenal insufficiency may mask its early diagnosis, and patients may present with unrecognized adrenal crisis. 20 PAL adrenal insufficiency is likely to happen if more than 90% adrenal tissue involved by the neoplasm and occurrence of Addisonian emergency can prompt to extreme life-threatening outcomes, therefore substitution therapy need to be taken into consideration of PAL. 21 The case in the current report had extensive bilateral infiltration the adrenal gland by the tumor.…”

Rare cause of adrenal insufficiency

“…PAL is more common in older men (median age 68 years and 2–3:1 male:female ratio) 3. The presentation is most often with bulky, bilateral disease 7. Most patients have B symptoms and elevated LDH 4.…”

Bilateral primary adrenal lymphoma with adrenal insufficiency

“…All of these symptoms can mask the adrenal insufficiency diagnosis and the patient could have presented with adrenal crisis if unrecognised early. In fact, 60–70% of adrenal lymphoma patients present with biochemical or clinical adrenal insufficiency9 irrespective of tumour size.…”

“…Ninety per cent of adrenal incidentalomas >4 cm in size are malignant. In addition, other radiological features are predictors of malignancy including irregular borders, calcifications, a heterogeneous mass with cystic degeneration and an attenuation of >20 HU on non-enhanced CT. Conversely, an absolute contrast medium washout of >50% after 10 min is 100% sensitive and specific for a benign adrenal lesion 9. MRI findings for adrenal lymphoma are characterised by low signal intensity on T1 and high signal intensity on T2 9…”